COMPREHENSIVE MANAGEMENT OF DENTAL, SKELETAL AND MUSCULAR DYSFUNCTION

ABSTRACT

A 9-year-old female patient reported with the chief complaint of inability to close the lips. Her parents also complained of protruded and irregularly aligned front teeth. Intra oral examination revealed that she had class I molar relationship, with severe crowding and proclination in both the arches. She had significantly increased interlabial gap. Model analysis showed TSALD and Bolton’s tooth size analysis showed mandibular excess. Treatment planning included early correction of musculature with pre-Orthodontic TRAINER, extraction of all first premolars and to allow drifting of the teeth in order to unravel crowding. This was to be followed by fixed mechanotherapy for closure of remaining extraction space and finishing and detailing. At the end of treatment, the patient had a pleasing profile, good intercuspation, ideal overjet, overbite and improved oro-facial muscle balance. Post treatment cephalometric evaluation showed acceptable maxillary and mandibular incisor inclinations, favorable growth pattern. The occlusion remained stable after orthodontic treatment.

Keywords:Early orthodontic treatment, Pre-Orthodontic TRAINER, premolar extraction, Driftodontics.

ACKNOWLEDGMENT

We would like to acknowledge the assistance received by Dr. Shreyaskar Rakshit and Dr. Gejo Johns.

INTRODUCTION

The use of pre-orthodontic appliances have been reported to produce skeletal, dentoalveolar and soft tissue changes.1-3 When treatment is based on correction of dental problems only, relapse could be expected. Therefore, treatment plan must include appliances to eliminate dysfunction of soft tissue and to correct the position of jaws and teeth.4 Recently, pre-orthodontic appliances have been developed and reported to produce significant changes in oral function which stimulates mandibular growth.5-7 By initiating treatment at the mixed dentition stage, the need for complex orthodontic treatment in permanent dentition can be minimized.8

Traditionally, in orthodontics extraction of teeth has been immediately followed by appliance therapy to prevent adverse and unwanted tooth movement. However, initiating orthodontic therapy immediately after extraction always may not be required. There are certain potential benefits from the period of physiological drift after extraction.9-11 The benefits include better occlusal relationship, spontaneous realignment of teeth and shorter period of fixed appliance therapy. Teeth have a natural tendency to drift into the extraction space. Extraction of first premolars is often associated with spontaneous decrowding of anteriors. Such spontaneous decrowding by drifting of teeth is referred to as Driftodontics. The term ‘Driftodontics’ was coined by R.G. “Wick” Alexander to describe the spontaneous unraveling of the lower anterior teeth without appliance therapy, making it much easier to place brackets after decrowding.12 

This case report describes the management of a case with pre-orthodontic trainer in the early childhood, and Driftodontics to unravel crowding spontaneously without orthodontic intervention, followed fixed mechanotherapy for finishing and detailing. 

DIAGNOSIS AND ETIOLOGY

A 9-year-old female patient reported to the author’s private clinic with the chief complaint of unaesthetic appearance of her teeth. Medical history and family history revealed no significant findings. On extraoral examination patient had convex profile, and severely incompetent lips with interlabial gap of 10mm (Fig 1). Intra oral examination revealed that patient was in mixed dentition. Severe crowding and proclination was seen in upper and lower arch. Maxillary arch was constricted in the anterior region. Patient had class I molar relation and increased overjet. Dental midlines were coinciding. Moyer’s total space analysis of the Pre treatment model showed tooth size arch length discrepancy (TSALD) of 8mm and Bolton’s analysis showed mandibular excess of 2.5mm. Pre treatment cephalometrics revealed that the patient is a vertical grower with proclined upper and lower an teriors. CVM indicators have shown that the patient was in the end of CVM II. Soft tissue parameters showed acute nasolabial angle and protrusive lower lips.
 (Fig 2 and Table 1)

http://guident.in/front/uploads/article-images/image_1574053252860.jpg

Figure 1: Pre treatment extra oral & intra oral photographs

http://guident.in/front/uploads/article-images/image_1574053113554.png

Figure 2: Pre treatment Lateral Cephalogram and OPG

http://guident.in/front/uploads/article-images/image_1574053227185.jpg

Figure 2: Pre treatment Lateral Cephalogram and OPG

TREATMENT OBJECTIVES

  • The treatment objectives were:
  • To correct the abnormal muscle activity.
  • To correct the proclination in both the arches.
  • To relieve the crowding.
  • To obtain ideal overjet and overbite.
  • To improve the arch form.
  • To achieve good soft tissue balance.
  • To correct Bolton’s and TSALD discrepancy.
  • To achieve good posterior occlusion. 

TREATMENT PLAN

The patient displayed aberrant perioral muscle function which included incompetent lips, hypertonic and short upper lip leading to an oro nasal breathing pattern. As the patient was in mixed dentition period, and had an Angle’s Class I Molar relationship with a Class II skeletal pattern, it was decided to maintain the Class I molar relation, it was decided to correct the abnormal muscle activity with Pre Orthodontic Trainer (POT). by redirecting muscular function to achieve a stable dentofacial change as opposed to advancing the mandible by using a functional appliance which would have ended in a Class III molar relationship that would require extraction only in lower arch which would leave the upper arch uncorrected. 

The POT therapy would be followed by re-evaluation of the case for extraction. Finishing and detailing would be carried out using fixed mechanotherapy.

TREATMENT PROGRESS

Patient was advised to wear Pre Orthodontic Trainer (POT) (T4K) one hour before sleep and to continue during sleep (Fig. 3). Pre Orthodontic Trainer (POT) was developed as early treatment modality for the child during mixed dentition period, when traditionally functional appliances work best. The Trainer acts like a functional appliance with some ‘headgear’ effect on the uppers. The use of Pre-Orthodontic Trainer (POT) was aimed at improving the circumoral muscular dysfunction and to redirect the muscular forces at an early age to achieve a stable balanced musculature.

The Pre Orthodontic Trainer (POT)¨ is a combined functional and tooth guidance appliance developed for the need of a comprehensive early treatment.

http://guident.in/front/uploads/article-images/image_1574053320571.png

Figure 3: Early intervention with Pre-Orthodontic TRAINER

Breathing holes were made in trainer, as patient was a mouth breather. Active supervision was carried out till the eruption of permanent dentition. Trainer was continued for 3 years with night time wears. Patient was re-evaluated at the age of 12 years. (Fig. 4) Clinical examination and cast analysis confirmed the need for extraction of first premolars to relieve crowding and proclination. Upper and lower 1st premolars were extracted and anteriors were allowed to drift into the extraction space for the alignment. At the end of six months, there was significant improvement in alignment. (Fig 5, 6)

http://guident.in/front/uploads/article-images/image_1574053370747.png

Figure 4: Intraoral photographs after Pre-Orthodontics Trainer

http://guident.in/front/uploads/article-images/image_1574053709331.jpg

Figure 5: Post driftodontics photographs

http://guident.in/front/uploads/article-images/image_1574053527605.png

Figure 6: Pre driftodontic lateral cephalogram and OPG

After decrowding, pre adjusted edgewise brackets (MBT prescription with 0.022 × 0.028-in slot) were bonded. Sequential alignment was carried out with 0.016 inch, 0.017 × 0.025 and 0.019 × 0.025 inch NiTi ach wire (Fig. 7). After leveling and alignment, remaining space was closed with 0.019 ×0.025 inch stainless steel archwire.

http://guident.in/front/uploads/article-images/image_1574053598478.png

Figure 7: Mid treatment photographs

TREATMENT RESULTS

Although the results were not ideal, the use of an orthodontic trainer did reduce the severity of malocclusion. These appliances correct muscle imbalance, improved tonicity and permit the teeth to occupy more stable physiological position in the oral cavity. After 15 months of fixed mechanotherapy, the patient had a Class I molar and Class I canine relation. (Fig 8) Midlines were coinciding. Ideal overbite and overjet was established. Teeth were well aligned and good arch form was achieved. The profile and lip competency improved, although slight lower lip protrusion persisted for which lip exercise such as water holding and button exercise had been prescribed. A wrap around retainer in the maxillary arch and fixed retainer in the lower arch were given after debanding. Post cephalometric evaluation showed some amount of skeletal correction, acceptable maxillary and mandibular incisor inclinations (Fig. 9) (Table 1). Though lateral cephalogram was not taken after POT therapy, post-driftodontics lateral cephalogram showed ANB correction of 3Ëš. The post treatment panoramic radiograph showed good root parallelism. (Fig 9) Pre treatment, post driftodontics and post-treatment superimposition showed good soft tissue balance. Overall Superimposition was carried out along SN plane registered at Sella. (Fig10) Patient was recalled and records were made at 1 year after debanding to check the stability of treatment. The occlusion remained stable after 1 year (Fig. 11).

http://guident.in/front/uploads/article-images/image_1574053848887.jpg

Figure 8: Post treatment extra oral and intra oral photographs

http://guident.in/front/uploads/article-images/image_1574053870585.png

Figure 9: Post treatment lateral cephalogram and OPG

http://guident.in/front/uploads/article-images/image_1574053922655.png

Figure 10: Superimposition of Pre, Mid and Post Lateral Cephalograms

http://guident.in/front/uploads/article-images/image_1574053975174.jpg

Figure 11: Post retention extra oral and intra oral photographs

DISCUSSION

Although controversy remains about the value of early orthodontic treatment, it is proved that many times patients may benefit from early orthodontic correction.2 Pre orthodontic appliances are prescribed to improve the harmony within the developing functional matrix of both the growing jaws and the dentoalveolar structures. As orthodontic forces applied to the growing face could alter the morphological outcome, force systems were incorporated to use the basic principles of force mechanics to optimize favorable jaw growth and dentoalveolar changes. This will enhance the function and esthetics while minimizing unfavorable responses. 

Soft tissues control the teeth position and should be treated in conjunction with orthodontic appliance therapy. Functional appliances have been extensively reported in the literature for treating malocclusions in growing children, as they may stimulate skeletal and soft tissue growth13. Pre Orthodontic Trainer (T4K®) is one of the effective appliances in early mixed dentition for eruption guidance and correction of myofunctional habits. Myofunctional training effects also corrects the faulty tongue position and oral habits, and harmonizes the tooth arches which are the cause of many malocclusions.4-6 The double mouthguard design of all TRAINER® System appliances trains the patient to breathe through the nose, improving cranio-facial growth when used in the developing child.

In orthodontic treatment with therapeutic extractions, the question always arises about the best time to start the fixed mechanotherapy. According to Alexander Philosophy, Driftodontics usually is performed for decrowding in the lower arch which is achieved by premolar extraction and without application of force.12 When the upper cuspids have been retracted to a Class I relationship, the lower arch should be bonded to allow time for driftodontics. The application of this concept will give the orthodontist the ability to position the brackets in perfect time, simplifying the need for use of additional resources to obtain space needed for orthodontic decrowding. Extraction site will begin to close by unraveling of incisor crowding with limited mesial movement of posterior teeth.

Although, serial extractions/ guidance of eruption are often indicated in mixed dentition cases with dento-alveolar disproportion in order to alleviate crowding of incisor teeth, it has serious side effects. According to Dewel (1967) 14, the most serious side effects are:

  1. Tendency of bite to close following loss of posterior teeth. A normal overbite depends on adequate vertical growth and Serial Extraction involves removal of strategically located deciduous and permanent teeth. Vertical and horizontal growth depends great part on normal proximal and occlusal function in maintaining arch length and normal overjet and overbite. 
  2. Second side effect is premolars that fail to reach their normal occlusal level. In normally developing dentition, the premolars are ready to emerge soon after the loss of the deciduous molars and then proceed occlusally with no delay. But in Serial Extraction cases the premolars have to travel a long way before penetrating the gingival tissues. Prolonged absence of teeth in the posterior segment of arches permits the tongue to flow into remaining spaces and this may remain as a tongue thrusting habit. This in turn prevents premolars from attaining full eruption.
  3. Nasal development is another unpredictable hazard. The nose is one structure that continues to grow long after other facial parts have reached maturity. Unrestrained extraction often accentuates its prominence by reducing skeletal development in dental area. Moreover growth of chin is unpredictable. If growth in nose and chin exceeds normal range a concave profile is obtained. 

Regarding therapeutic extractions a popular misconception exists that, Biphasic treatment mandates a non-extraction protocol. But as David Hamilton (1997) mentioned, if the decision is made to treat a child during the mixed dentition period the chances that two stages of treatment will be required, are also increased. In such cases several legitimate options or treatment plans should be considered, the final decision may be to begin staged treatment early but delay irreversible decisions until early treatment outcomes can be evaluated. Thus, a Biphasic treatment does not exclude treatment with extraction.15

In this case, patient was given a Pre-orthodontic trainer (POT) and supervised for 3 years. The aim of the Pre-orthodontic trainer (POT) therapy was to utilize the growth potential of the jaw and redirecting the muscular activity towards achieving a balanced musculature. Uysal et al (2011) reported that POT appliance showed a positive influence on the masticatory and perioral musculature.16

This also allowed keeping open the option of a conservative treatment plan at an early age and providing the patient with psychosocial benefits by decreasing the severity of malocclusion while making the second phase treatment more stable.

After trainer therapy, extractions of all first premolars were done and teeth were allowed for drifting to relieve crowding. As a part of orthodontic treatment, most of the cases require a phase two with fixed mechanotherapy for finishing and detailing.17 Fixed orthodontic mechanotherapy was continued for 1 year.

This case report is an excellent example of correcting all the three systems- skeletal, dental and muscular which are responsible for malocclusion. The muscles are trained and these forces are harnessed to bring about dental and skeletal correction. Successful outcome for treatment with functional appliances can be associated with the patient’s age and the severity of the malocclusion. While the amount of growth is determined by both genetic and environmental influence, redirecting the activity of the facial muscles, particularly labial musculature has also been reported to influence the response and duration of treatment for class II malocclusions. It is also inferred that growth of the jaws as well as the position of the teeth can be guided to a more favorable position using pre orthodontic trainer.18 Driftodontics helped in decrowding and alignment naturally, even before using fixed mechanotherapy. The advantage here is, balance in dental, skeletal and soft tissue leading to greater stability.

CONCLUSION

Apart from self esteem, intervention in the early mixed dentition with pre orthodontic appliances appears to be an effective method to correct malocclusions by acting on muscular dysfunction and to stimulate the transverse and sagittal development. Driftodontics after extraction of first premolars can produce desirable changes in decrowding and alignment which will shorten the duration of orthodontic treatment. The extraction site will begin to close mainly by drifting of anteriors and molars remains stable. 

REFERENCES

  1. Nelson C, Harkness M, Herbison P. Mandibular changes during functional appliance treatment. Am J Orthod Dentofacial Orthop. 1993;104(2):153-61.
  2. Tulloch JF, Proffit WR, Phillips C. Influences on the outcome of early treatment for Class II malocclusion. Am J Orthod Dentofacial Orthop. 1997;111:533-42.
  3. Toth LR, McNamara JA Jr. Toth LR, McNamara JA Jr. Treatment effects produced by the twin-block appliance and the FR-2 appliance of Fränkel compared with an untreated Class II sample. Am J Orthod Dentofacial Orthop. 1999 ;116:597-09.
  4. Tallgren A, Christiansen R, Ash MM, Miller RL. Effects of a myofunctional appliance on crofacial muscle activity and structures. Angle Orthod. 1998;3:249–58
  5. Dinkova M. Vertical control of overbite in mixed dentition by trainer system. J of IMAB 2014;20:648-654
  6. Uysal T, Yagci A, Kara S, Okkesim S. Influence of pre-orthodontic trainer treatment on the perioral and masticatory muscles in patients with Class II division 1 malocclusion. Eur J Orthod. 2012 ;34:96-101.
  7. Usumez S, Uysal T, Sari Z, Basciftci FA, Karaman AI, Guray E.The effects of early preorthodontic trainer treatment on Class II, division 1 patients. Angle Orthod. 2004 ;74:605-9.
  8. Wagers, L.E. Pre-orthodontic guidance and the corrective mixed-dentition treatment concept. Am J Orthod. 1976;69:1–28.
  9. Papandreas SG, Buschang PH, Alexander RG, Kennedy DB, Koyama I.Physiologic drift of the mandibular dentition following first premolar extractions. Angle Orthod. 1993 ;63:127-34.
  10. Mamopoulou A, Hägg U, Schröder U, Hansen K.Agenesis of mandibular second premolars. Spontaneous space closure after extraction therapy: a 4-year follow-up.Eur J Orthod. 1996 Dec;18(6):589-600.
  11. Stephens CD. The rate of spontaneous closure at the site of extracted mandibular first premolars. Br J Orthod. 1983 Apr;10(2):93-7.
  12. Alexander, R.G. “Wick”. Chapter Principle 18: Use Extraction Treatment When NecessaryThe 20 Principles of the Alexander Discipline, Volume 1Quintessence Publishing Co, Inc page no 180-201
  13. Ruf S, Pancherz H. Herbst/multibracket appliance treatment of Class II division 1 malocclusions in early and late adulthood. A prospective cephalometric study of consecutively treated subjects. Eur J Orthod 2006;28:352-60.
  14. Dewel BF. Serial extraction: its limitations and contraindications in orthodontic treatment. Am J Orthod. 1967 ;53(12):904-21.
  15. Graber TM, Rakosi T, Petrovic AG. Dentofacial orthopedics with functional appliances. C.V. Mosby Co. St. Louis.; 1997 2nd Ed. Chapter 15; pp. 449
  16. Uysal T, Yagci A, Kara S, Okkesim S. Influence of pre-orthodontic trainer treatment on the perioral and masticatory muscles in patients with Class II division 1 malocclusion. Eur J Orthod 2011 Jan 6;34(1):96-101.
  17. Gianelly AA. One-phase versus two-phase treatment. Am J Orthod Dentofacial Orthop. 1995 ;108(5):556-9.
  18. Tulloch JC, Proffit WR, Phillips C. Influences on the outcome of early treatment for Class II malocclusion. Am J Orthod Dentofacial Orthop. 1997;111(5):533-42.

 

Leave a Comment